Provider First Line Business Practice Location Address:
134 69TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92114-5902
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
858-310-7883
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/12/2026